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STATE OF CALIFOR* WATER RESOURCES CONT0 BOARD <br /> FORM 'B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .� <br /> MARK ONLY ❑ I NEWPERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ,, 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: (� �{-� Eco FARM TANK-YES❑ NO z <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 <br /> A. OWNERS TANK ID# Q/VV�c' B. MANUFACTURED BY: llyr- <br /> C.YEAR INSTALLED 1qj,2sj D. TANK CAPACITY IN GALLONS: w <br /> 11. TANK C LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 0 6 AVIATION GAS <br /> 0 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 C.A.S.# C.A.S.#: <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,8 D <br /> A.TYPE OF ❑1 BLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR UNBI 95 UNKNOWN <br /> SYSTEM 2 SING WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> STEEUIRON 2 STAINLESS MEL ❑39BERGLASS 4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> B.TANK F-] 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE PRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2AU(YD LINING 3EPDXY LINING 4PHENOLIC LINING <br /> C.INTERIOR 5 GLASS UNING VZlTNUNED 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 109%METHANOL? YES D NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 2 OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A J01 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A V 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FAP A U B 1 OD%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 1 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 31 WAS TA NK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES D NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> n [ Fo o <br /> CU ENT LOCAL AGENCY FACILITY ID# AP D BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE P MITEXPIRATIO DATE <br /> CHECK# PERMITAMOUNT S CHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITEDATA PROCESS NFORMDPA',UNLESS A C NT FORMA' HAS BEEN FILED <br />